Therapeutic drug monitoring in epilepsy clinic: a multi-disciplinary approach

Role of clinical pharmacists in epilepsy management at a general hospital in Vietnam: a before-and-after study

Background

Clinical pharmacists have an important role in inter-professional healthcare collaboration for epilepsy management. However, the pharmacy practices of managing epilepsy are still limited in Vietnam, deterring pharmacists from routine adjustments of antiepileptic drugs, which could decrease the patients’ quality of life. This study aimed to assess the effectiveness of pharmacist interventions in epilepsy treatment at a Vietnamese general hospital.

Methods

A before-and-after study was conducted from January 2016 to December 2018. All patients with a diagnosis of epilepsy and being treated at the investigated hospital were recruited and screened for eligibility and exclusion criteria. The primary outcome was the proportion of patients in good control of their epilepsy (with two seizures or less in a year). The secondary outcome was the number of patients maintaining optimized concentrations within the therapeutic range of carbamazepine (4–12 mg/L), phenytoin (10–20 mg/L), or valproic acid (50–100 mg/L). Collected data were analyzed using two proportions Z-test or Chi-square test.

Results

A total of 141 participants were enrolled in the study. While most patients were given lower prescribed daily doses than the recommendations from the World Health Organization, over 56% of the participants still experienced adverse drug effects. More than half of the patients received at least one pharmacists’ intervention, which increased by 25.0% the effectiveness of the therapy (p < 0.001) and by 14.6% the number of patients with optimized drug concentrations (p = 0.018).

Conclusion

Epilepsy management requires a multiple-stepped and comprehensive approach, with a focus on the health and safety of the patients. As part of the healthcare team, pharmacists need to engage at every stage to monitor the patient’s response and determine the most effective treatment with the fewest adverse drug reactions.

Trial registration ClinicalTrials.gov, NCT04967326. Registered July 19, 2021—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04967326

Implementation of an older adult epilepsy clinic utilizing pharmacist services

BACKGROUND

Antiseizure medications are commonly associated with adverse effects including behavioral and cognitive issues, drug interactions, idiosyncratic reactions, and long-term complications, which can lead to non-adherence. At the same time, there are limited reports describing multidisciplinary models of epilepsy care that include pharmacists.

OBJECTIVE

To describe the pharmacist services in an epilepsy clinic for older adults and document the patient care delivered using this design.

PRACTICE DESCRIPTION

A subspecialty older adult epilepsy clinic, embedded within a neurology clinic, in an urban academic medical center.

PRACTICE INNOVATION

Integration of pharmacy services to document medication history, provide medication reconciliation, identify medication-related problems, and make interventions.

EVALUATION METHODS

Data were retrospectively evaluated for the patients seen by the pharmacist and epilepsy team between July 2019 and January 2021. Data were summarized with descriptive statistics.

RESULTS

Fifty-eight patients with a total of 94 encounters (70.7% of all specialty clinic visits) were seen collaboratively by the physician and the pharmacist. The majority of patients were African American (87.9%), aged 63.7 ± 8.2 years, and more frequently male (58.6%), and a high proportion had some baseline memory loss or diagnosis of dementia (53.4%). Medication reconciliation occurred in 94 (100%) encounters. More than half the encounters required reconciliation to the existing medication list by adding medication (55.3 % of encounters) or deleting mediations (53.2% of encounters). Presence of adverse effects was the most common medication-related problem identified (23.4%). Resolutions to the medication-related problems were also reported.

CONCLUSION

The population of older adults with epilepsy is expected to increase in prevalence. Pharmacists are able to impact medication-related problems in a vulnerable, high-risk patient population. The multidisciplinary model we describe here can be used as a template to provide care in ambulatory care practices involving other neurology specialties with a high proportion of older adult patients.

Evaluating the impact of pharmaceutical care services on the clinical outcomes of epilepsy: a randomised controlled trial

BACKGROUND

The involvement of pharmacists in the provision of specialised care to patients with epilepsy is poor.

OBJECTIVE

To evaluate the impact of pharmaceutical care services on the clinical outcomes of epilepsy.

SETTING

Two selected major referral epilepsy treatment centres in southern Nigeria were used for the study. Patients were recruited from the Neurology and Medical out-patient clinics of the hospitals.

METHOD

An open randomised controlled study was carried out on epilepsy patients receiving clinical care at the selected hospitals. Patients in the intervention group were offered pharmaceutical care services. The impact of the pharmaceutical care services on the clinical outcomes of epilepsy (seizure frequency and severity) was evaluated.

MAIN OUTCOME MEASURE

The effect of pharmaceutical care services on seizure frequency and severity in patients with epilepsy.

RESULTS

There was a statistically significant difference between the usual care (UC) and the pharmaceutical care (PC) group on the clinical outcomes of epilepsy post-PC intervention. Comparison between the groups (UC versus PC) revealed that patients in the PC group had a significantly lower seizure frequency score than those in the UC group at 3 months and 6 months-(pre-intervention: 3.09 versus 3.34; t = -1.685; p = 0.094) (3 months 2.45 versus 1.68; t = 4.494; p = 0.001), (6 months: 1.97 versus 0.92; t = -3.137; p = 0.001). Also, comparisons between the groups (UC versus PC) showed that patients in the PC group had a significantly lower seizure severity score than those in the UC group at 3 months and 6 months-(pre-intervention 18.46 versus 20.38; t = -3.102; p = 0.01) (3 months: 17.51 versus 14.79; t = 4.202; p = 0.001) (6 months 16.41 versus 11.66; t = 8.930; p = 0.001).

CONCLUSION

Pharmaceutical care interventions may significantly reduce seizure frequency and severity in patients with epilepsy.

IMPACT OF FINDINGS ON PRACTICE

These findings provide justification for the integration of pharmaceutical care services with other elements of health care for epilepsy patients.

Applying a perceptions and practicalities approach to understanding nonadherence to antiepileptic drugs

OBJECTIVE

Nonadherence to antiepileptic drugs (AEDs) is a common cause of poor seizure control. This study examines whether reported adherence to AEDs is related to variables identified in the National Institute for Health and Clinical Excellence (NICE) Medicines Adherence Guidelines as being important to adherence: perceptual factors (AED necessity beliefs and concerns), practical factors (limitations in capability and resources), and perceptions of involvement in treatment decisions.

METHODS

This was a cross-sectional study of people with epilepsy receiving AEDs. Participants completed an online survey hosted by the Epilepsy Society (n = 1,010), or as an audit during inpatient admission (n = 118). Validated questionnaires, adapted for epilepsy, assessed reported adherence to AEDs (Medication Adherence Report Scale [MARS]), perceptions of AEDs (Beliefs about Medicines Questionnaire [BMQ]), and patient perceptions of involvement in treatment decisions (Treatment Empowerment Scale [TES]).

RESULTS

Low adherence was related to AED beliefs (doubts about necessity: t(577) = 3.90, p < 0.001; and concerns: t(995) = 3.45, p = 0.001), reported limitations in capability and resources (t(589) = 7.78, p < 0.001), and to perceptions of a lack of involvement in treatment decisions (t(623) = 4.48, p < 0.001). In multiple logistic regression analyses, these factors significantly (p < 0.001) increased variance in reported adherence, above that which could be explained by age and clinical variables (seizure frequency, type, epilepsy duration, number of AEDs prescribed).

SIGNIFICANCE

Variables identified in the NICE Medicines Adherence Guidelines as potentially important factors for adherence were found to be related to adherence to AEDs. These factors are potentially modifiable. Interventions to support optimal adherence to AEDs should be tailored to address doubts about AED necessity and concerns about harm, and to overcome practical difficulties, while engaging patients in treatment decisions.